Prescription Monitoring Program

Prescription Monitoring Program: Prescriber Registration

PLEASE NOTE: If you have registered in the past, but cannot remember your credentials, you do not need to register again. Please contact us at: (217) 524-1311

Please complete and submit the following form. We will use the information to verify your identity and the authenticity of your access request. License status will be verified by using the applicable state's professional license lookup services. Submitted information will remain confidential.

For verification purposes, all information is required and will be kept confidential.

Prescriber Information

Prescriber Work E-mail Address (To prevent delays in account approval, please use work email.)

All communications will be sent to this email address, including information that will help you recover your ID or password.

Re-type Work E-mail Address

Please enter your email address again to help ensure accuracy.

Password

8 to 32 characters with at least 1 number and 1 upper and lower case letters. Do NOT use your email password.

Re-type Password

Please re-type the password to help ensure accuracy.

Prescriber Last Name

Prescriber First Name

Name of Practice

Type of Practice

Other Type of Practice

Business Address

City

State

Zip Code

Prescriber DEA Number

Practice Phone Number

() - -

Ext:

Contact Hours

Enter in any format, the day and time we would most likely be able to reach you by phone at your practice.

Licensing State

Illinios State License Number This is your standard license number and not controlled substance license Number

ex: 123 456789

License Number

NPI Number

If you don't have one, leave blank.

Method of Referral

Other Method

Terms and Use Agreement

- The use of the Prescription Inquiry Library (PMP) is intended for and may be only used for medical purposes. 
                
                - I give the Prescription Monitoring Program and its representatives permission to contact me through the contact information I provided.
                
                - I understand that Illinois Law (720 ILCS 570/318) and US PL 104-191 prohibit the disclosure or discussion of any personal health information without proper written authorization. 
                
                - I understand that I am personally responsible for all usage associated with this user ID. 
                
                - I further understand that system usage is logged, and my access to the system may be denied or revoked at the discretion of the IDHS Bureau of Pharmacy and Clinical Support Services' Prescription Monitoring Unit.

I Agree I Disagree

If you select "I do not agree", please call (217) 524-1311.

Note: Please allow 1-2 business days for application processing. Your account will not be activated until we have contacted you.